Few residents alive and walking 1 year after lower extremity revascularization.

Functional gains were not typical -- and perhaps not expected -- with peripheral arterial disease (PAD) procedures among nursing home residents, a national analysis showed.

One year after lower extremity revascularization, 51% had died, 28% were not ambulatory, and 32% had declined functionally, Emily Finlayson, MD, director of the University of California San Francisco's Center for Surgery in Older Adults, and colleagues reported online in JAMA Internal Medicine.

The biggest drops in function were seen among the quarter of patients who were walking before the procedure. Among them, 63% had died or were no longer ambulatory after 1 year.

"In short, lower extremity revascularization was relatively ineffective in terms of preserving or enhancing the functional state or the ability to walk of nursing home residents and was associated with a high likelihood of dying within 12 months," William J. Hall, MD, of the University of Rochester, N.Y., summarized in an accompanying editorial.

But because 75% weren't walking to start with, that probably wasn't the primary goal (although not explicitly available in the analysis), he noted.

"Rather, most of the procedures were probably performed for relief of symptoms secondary to ischemic leg pain, nonhealing wounds or worsening gangrene," he wrote. "In this context, lower extremity revascularization should be viewed as a palliative measure rather than as a definitive therapeutic procedure to extend life or ambulatory function."

Few guidelines address PAD in nursing home residents specifically, but it's reasonable to include selective surgical interventions like this in attention to their pain and symptom control, Hall suggested.

"The best care will be patient and family centered, interdisciplinary, and characterized by communication and determining the goals of care," he noted.

Significant independent factors associated with death or inability to walk were:

Age 80 or older (adjusted hazard ratio 1.28)

Cognitive impairment (AHR 1.23)

Nonambulatory status before surgery (AHR 1.88)

Decline in activities of daily living before surgery (AHR 1.23)

Congestive heart failure (AHR 1.16)

Renal failure (AHR 1.09)

Emergent surgery (AHR 1.29)

The analysis included 10,784 long-staying nursing home residents in the 100% Medicare Inpatient File who got lower extremity revascularization from 2005 to 2008 (about half endovascular versus open). The claims data was combined with that from the Minimal Data Set (MDS 2.0) from federally-mandated clinical assessments of ambulatory, mental, and functional status.

Finlayson was supported by a National Institute on Aging/Paul B. Beeson Clinical Scientist Development Award in Aging and the University of California San Francisco's Claude D. Pepper Older Americans Independence Center.

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